Repeated warnings

Each one is a single concern, raised with the same organisation in two or more coroners' reports at least six months apart. Nemotron Super judged every match to be the same or a closely related hazard, and both quotes are checked word for word against the reports.

Organisation type

Ambulance service25 Commissioner6 Company or provider10 Local authority28 National body342 NHS body175 Police28 Prison or detention12 Other40

Theme

Care homes28 Child deaths64 Custody and policing46 Drugs, alcohol and medication32 Emergency and community care46 Hospital care108 Mental health72 Products and workplaces9 Roads and rail53 Suicide Other11

Relation

Identical Closely related

Reports

3+ reports

More filters

Minimum confidence

0.80+0.90+

At least

5 reports 10 reports

Active:Suicide Clear all

197 chains, most recent report first. The order is by date only; there is no ranking of organisations.

Inadequate ACCT review for high-risk prisoners
Ministry of Justice · National body
5 reports · 5 coroners
Closely relatedConfidence 0.80 · moderateNo published response to an earlier report
Inadequate risk information sharing and documentation
Ministry of Defence · National body
2 reports · 2 coroners
Closely relatedConfidence 0.90 · high
Lack of independence leads to non-disclosure fears
Ministry of Defence · National body
2 reports · 2 coroners
Closely relatedConfidence 0.92 · high
Inadequate supervision of care coordinator role
Oxford Health NHS Foundation Trust · NHS body
2 reports · 2 coroners
Closely relatedConfidence 0.85 · highNo published response to an earlier report
Restricted smoking options increase self-harm risk
NHS England · National body
2 reports · 2 coroners
Closely relatedConfidence 0.80 · moderateNo published response to an earlier report
Inadequate record keeping of claimant interactions
Department for Work and Pensions · National body
2 reports · 2 coroners
Closely relatedConfidence 0.90 · high
Easy access to suicide instructions online and in print
Department for Culture · National body
2 reports · 2 coroners
Closely relatedConfidence 0.90 · highNo published response to an earlier report
Inadequate verification of leave conditions
Coventry and Warwickshire Partnership NHS Trust · NHS body
2 reports · 2 coroners
Closely relatedConfidence 0.90 · high
Limited placement options for autistic young adults at risk of self-harm or harming others
NHS England · National body
2 reports · 2 coroners
Closely relatedConfidence 0.85 · highNo published response to an earlier report
Physical health check delays mental health referrals
Norfolk and Suffolk NHS Foundation Trust · NHS body
5 reports · 4 coroners
Closely relatedConfidence 0.80 · moderateNo published response to an earlier report
Fragmented mental health record keeping
Greater Manchester Mental Health NHS Foundation Trust · NHS body
2 reports · 2 coroners
Closely relatedConfidence 0.86 · high
Detention without section due to bed shortage
NHS England · National body
2 reports · 2 coroners
Identical hazardConfidence 0.90 · highNo published response to an earlier report
Inadequate communication between agencies
Sussex Police · Police
3 reports · 3 coroners
Closely relatedConfidence 0.90 · highNo published response to an earlier report
Lack of suicide intervention training for front line police staff
Sussex Police · Police
2 reports · 1 coroner
Closely relatedConfidence 0.80 · moderateNo published response to an earlier report
Lack of mental health risk assessment training and timely referrals
Surrey Police · Police
2 reports · 2 coroners
Closely relatedConfidence 0.90 · high
Inadequate out-of-hours information sharing in SCARF process
Surrey Police · Police
2 reports · 2 coroners
Identical hazardConfidence 0.95 · high
Lack of mental health act assessment before release
West Midlands Police · Police
2 reports · 2 coroners
Closely relatedConfidence 0.90 · high
Medical information not disclosed to firearms licensing authority
National Police Chiefs' Council · National body
2 reports · 2 coroners
Closely relatedConfidence 0.85 · highNo published response to an earlier report
Welfare checks missed and undocumented
HMP Swaleside · Prison or detention
3 reports · 1 coroner
Closely relatedConfidence 0.90 · high
Incomplete or meaningless ACCT observations in prison
His Majesty's Prison and Probation Service · National body
2 reports · 2 coroners
Closely relatedConfidence 0.90 · highNo published response to an earlier report

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